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Harris AB, Valenzuela J, Andrade N, Agarwal A, Gu A, Golladay G, Thakkar S. Comparison of Pneumonia and Major Complications After Total Joint Arthroplasty With Spinal Versus General Anesthesia: A Propensity-matched Cohort Analysis. J Am Acad Orthop Surg 2024; 32:33-40. [PMID: 37603703 DOI: 10.5435/jaaos-d-23-00192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/05/2023] [Indexed: 08/23/2023] Open
Abstract
INTRODUCTION Spinal anesthesia (SA) allows total joint arthroplasty to be done while minimizing opioids and systemic anesthetic agents compared with general anesthesia (GA). SA has been associated with shortened postoperative recovery; however, the relationship between SA, major postoperative complications, and pneumonia (PNA) remains unclear. METHODS Patients in a large, national database who underwent total hip arthroplasty or total knee arthroplasty from 2010 to 2020 were identified. 1:1 propensity score matching was used to create matched groups of patients who underwent SA and GA. The groups were matched by age, sex, chronic obstructive pulmonary disease, smoking status, Charlson Comorbidity Index, and American Society of Anesthesiology (ASA) classification. 1:1 matching was also done among the ASA classifications as a subanalysis. RESULTS Overall, equally matched groups of 217,267 patients who underwent SA versus GA were identified. 850 patients (0.39%) developed postoperative PNA after GA versus 544 patients (0.25%) after SA ( P < 0.001). The risk of major complications was 6,922 (3.2%) in the GA group and 5,401 (2.5%) in the SA group ( P < 0.001). Similarly, the risk of unplanned postoperative reintubation was higher (0.18% versus 0.10%, P < 0.001) and mortality was higher (0.14% versus 0.09%, P < 0.001) in the GA group than in the SA group. In ASA 1 to 3 patients, the risk of PNA was 0.08% to 0.21% higher with GA than with SA. In ASA 4 patients, the risk of PNA was 0.42% higher in SA than in GA (1.92% versus 1.5%, P < 0.001) and the mortality rate was nearly doubled in GA than in SA (1.46% versus 0.77%, P = 0.017). DISCUSSION Overall, GA was associated with a small but markedly higher rate of major complications, mortality, and PNA than SA in patients undergoing total joint arthroplasty when matching for differences in comorbidities. ASA 4 patients experienced the greatest increase in absolute risk of mortality with GA versus SA.
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Affiliation(s)
- Andrew B Harris
- From the Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD (Harris, and Thakkar), the California Health Sciences University, Clovis, CA (Valenzuela), the Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, MD (Andrade), the Department of Orthopaedic Surgery, The George Washington University, Washington, DC (Agarwal, and Gu), the Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA (Golladay), and the Orthopaedics Research Collaborative (ORC) (Harris, Gu, Golladay, and Thakkar)
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Chowdary AR, Beale J, Martinez J, Aggarwal V, Mounasamy V, Sambandam S. Postoperative complications of spinal vs general anesthesia in elderly patients undergoing hip hemiarthroplasty. Arch Orthop Trauma Surg 2023; 143:5615-5621. [PMID: 37061659 DOI: 10.1007/s00402-023-04876-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION Elderly patients with hip fractures are at high risk for mortality due to postsurgical complications. Hip hemiarthroplasty is a routine procedure done in elderly patients for surgical repair of femoral neck fractures. Both general and spinal anesthesia can be used in elderly patients undergoing hemiarthroplasty. Rates of postoperative complications among the two anesthetic choices have not been directly compared. In this study, we compare the rates of postoperative complications in elderly patients (age greater than 70) undergoing hip hemiarthroplasty for femoral neck fractures using a national database. METHODS Data for the years 2015-2020 from the National Surgical Quality Improvement Program (NSQIP) were used for the study. Patients greater than 70 years of age who received a hip hemiarthroplasty with general anesthesia or spinal anesthesia were identified using CPT procedure codes. Pertinent preoperative variables and rates of postoperative complications were characterized and analyzed. RESULTS Our study found that elderly patients who received spinal anesthesia had, on average, longer length of stays but shorter operative times compared to patients who received general anesthesia. Furthermore, we found that patients who received spinal anesthesia had lower rates of systemic sepsis, cardiac arrests, and blood transfusions when compared to patients who received general anesthesia. Finally, we found that overall rates of mortality were significantly lower in the spinal anesthesia cohort compared to the general anesthesia cohort. CONCLUSION Our work suggests that patients who underwent spinal anesthesia for hip arthroplasty may have lower rates of postoperative complications. This work further highlights the role of anesthetic choice in preventing complications following hip hemiarthroplasty procedures.
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Affiliation(s)
| | - Jack Beale
- Department of Orthopedics, University of Texas Southwestern, Dallas, TX, USA
| | - Jack Martinez
- Department of Orthopedics, University of Texas Southwestern, Dallas, TX, USA
| | - Vikram Aggarwal
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Varatharaj Mounasamy
- Department of Orthopedics, University of Texas Southwestern, Dallas, TX, USA
- Department of Orthopedics, Dallas VA Medical Center, Dallas, TX, USA
| | - Senthil Sambandam
- Department of Orthopedics, University of Texas Southwestern, Dallas, TX, USA.
- Department of Orthopedics, Dallas VA Medical Center, Dallas, TX, USA.
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Owen AR, Amundson AW, Fruth KM, Duncan CM, Smith HM, Johnson RL, Taunton MJ, Pagnano MW, Berry DJ, Abdel MP. Spinal versus General Anesthesia in Contemporary Revision Total Hip Arthroplasties. J Arthroplasty 2023:S0883-5403(23)00240-1. [PMID: 36931357 DOI: 10.1016/j.arth.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/19/2023] Open
Abstract
INTRODUCTION Spinal anesthesia is increasingly used in complex patient populations including revision total hip arthroplasties (THAs). This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anesthesia in a large institutional series of revision THAs. METHODS We retrospectively identified 4,767 revision THAs (4,533 patients) from 2001 to 2016 using our institutional total joint registry. Of these cases, 86% had general and 14% had spinal anesthesia. Demographics between groups were similar with mean age of 66 years, 52% women, and mean BMI of 29. Complications including all-cause re-revisions and reoperations were studied. Data were analyzed using an inverse probability of treatment weighted model based on propensity score that accounted for patient and surgical factors. The mean follow-up was 7 years. RESULTS Patients treated with spinal anesthesia required fewer postoperative oral morphine equivalents (OMEs) (P<0.001) and had lower numeric pain rating scale scores (P<0.001). Spinal anesthesia had a decreased LOS (4.2 vs. 4.8 days; P=0.007), fewer cases of altered mental status (AMS; Odds Ratio (OR) 3.1, P=0.001), fewer blood transfusions (OR 2.3, P<0.001), fewer intensive care unit (ICU) admissions (OR 2.3, P<0.001), fewer re-revisions (OR 1.6, P=0.04), and fewer reoperations (OR 1.5, P=0.02). DISCUSSION Spinal anesthesia was associated with lower OME use and reduced LOS in this large cohort of revision THAs. Furthermore, spinal anesthesia was associated with fewer cases of AMS, transfusion, ICU admission, re-revision, and reoperation after accounting for numerous patient and operative factors.
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Affiliation(s)
- Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Adam W Amundson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Kristin M Fruth
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Christopher M Duncan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Hugh M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Michael J Taunton
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
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Sowers M, Jacob R, Chandler K, Kuntz GE, Rajaram S, Kukreja P, Naranje S. Operative room time comparison between general and spinal anesthesia in total hip arthroplasty: an institutional study. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04775-4. [PMID: 36695906 DOI: 10.1007/s00402-023-04775-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/07/2023] [Indexed: 01/26/2023]
Abstract
PURPOSE A relatively high expense with any procedure is total operative time; two components being the time spent anesthetizing the patient and time spent transferring the patient out of the operating room (OR). Both times can be affected by the anesthetic method used. This study compares different operative time intervals for both spinal anesthesia (SA) and general anesthesia (GA), in patients undergoing a primary total hip arthroplasty (THA), to identify the most appropriate and cost-effective anesthetic method. METHODS A retrospective chart review was performed at a single institution for primary total hip arthroplasty procedures performed in the year 2019. Primary THAs without complications performed by three orthopedic surgeons were selected. Anesthesia records for 200 patients were used to compare perioperative time intervals; 100 consecutive patients that received SA and 100 consecutive patients that received GA. RESULTS The time spent transferring the patient out of the operating room was 8 min for GA and 5 min for SA (p < 0.001). Total operative time for GA was 90 min and 87 min for SA (p = 0.3330). Total pre-operative time averaged 26 min in SA compared to 25 min in GA (p = 0.5874). Non-operative total time (all time components of patient interaction excluding surgery start to surgery finish) was significantly shorter in SA with an average of 52 compared to 56 in GA (p = 0.0151). CONCLUSION Time to transfer patient out of the OR and total non-operative time was significantly shorter in patients who received spinal anesthesia. These results and the complications of both general and spinal anesthesia should be taken into consideration when anesthetizing patients undergoing primary THA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mackenzie Sowers
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1201 11th Ave S #200, Birmingham, AL, 35205, USA
| | - Roshan Jacob
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1201 11th Ave S #200, Birmingham, AL, 35205, USA
| | - Kelly Chandler
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1201 11th Ave S #200, Birmingham, AL, 35205, USA
| | - George E Kuntz
- Department of Anesthesiology, University of Alabama at Birmingham, JT 845 619 South 19th Street, Birmingham, AL, 35249, USA
| | - Sakthivel Rajaram
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1201 11th Ave S #200, Birmingham, AL, 35205, USA
| | - Promil Kukreja
- Department of Anesthesiology, University of Alabama at Birmingham, JT 845 619 South 19th Street, Birmingham, AL, 35249, USA
| | - Sameer Naranje
- Division of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1201 11th Ave S #200, Birmingham, AL, 35205, USA.
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Wang AY, Ahsan T, Kosarchuk JJ, Liu P, Riesenburger RI, Kryzanski J. Assessing the Environmental Carbon Footprint of Spinal versus General Anesthesia in Single-Level Transforaminal Lumbar Interbody Fusions. World Neurosurg 2022; 163:e199-e206. [PMID: 35342029 DOI: 10.1016/j.wneu.2022.03.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/21/2022] [Accepted: 03/21/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The U.S. health care sector produces approximately 10% of national greenhouse gas emissions, paradoxically harming human health. Neurosurgery is a resource-intensive specialty that likely contributes significantly, yet literature assessing this impact is absent. We investigate the difference in carbon emissions between spinal versus general anesthesia in lumbar spine surgery. METHODS A total of 100 patients underwent a single-level transforaminal lumbar interbody fusion (TLIF) from a single surgeon; 50 received spinal anesthesia and 50 received general anesthesia. Data were extracted from patient records. Amounts of anesthetics were calculated from intraoperative records and converted to carbon dioxide equivalents (CO2e). RESULTS The median CO2e for general anesthesia was 4725 g versus 70 g for spinal anesthesia (P = 7.07e-18). The mean CO2e for general anesthesia was 22,707 g versus 63 g for spinal anesthesia. Desflurane use led to outsized carbon emissions. Carbon footprint comparisons are made with familiar units such as miles driven by a car, and are provided for a single TLIF, 50 TLIFs (single surgeon's cases in a year), and 488,000 TLIFs (annual spinal fusions in the United States). CONCLUSION This is one of the first known comparative carbon footprint studies performed in neurosurgical literature. We highlight the dramatic carbon footprint reduction associated with using spinal anesthesia and reflect a single neurosurgeon's change in practice from using only general anesthesia to incorporating the use of spinal anesthesia. Within general anesthesia patients, desflurane use was particularly harmful to the environment. We hope that our study will pave the way toward future research aimed at uncovering and reducing neurosurgery's environmental impact.
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Affiliation(s)
- Andy Y Wang
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Tameem Ahsan
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jacob J Kosarchuk
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Penny Liu
- Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA.
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DeMik DE, Carender CN, Glass NA, Brown TS, Callaghan JJ, Bedard NA. Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty? J Arthroplasty 2022; 37:S63-S69.e1. [PMID: 34511282 DOI: 10.1016/j.arth.2021.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Incidence of blood transfusions after primary and revision total hip and knee arthroplasty (primary total hip arthroplasty [pTHA], revision THA [rTHA], primary total knee arthroplasty [pTKA], and revision TKA [rTKA]) has been decreasing for a multitude of reasons. The purpose of this study was to assess whether transfusion rates have continued to decline and evaluate patient factors associated with transfusions. METHODS The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA, pTKA, rTHA, and rTKA between 2011 and 2019. Patients undergoing bilateral procedures and arthroplasty for fracture, infection, or tumor were excluded. Trends in blood transfusions were assessed. Patient factor association with blood transfusions was evaluated using 2018 and 2019 data. RESULTS Transfusion rates decreased from 21.4% in 2011 to 2.5% in 2019 for pTHA (P < .0001). For pTKA, transfusion rates declined from 17.6% to 0.7% (P < .0001). In rTHA, the transfusion rate decreased from 33.5% to 12.0% from 2011 to 2019 (P < .0001). Transfusion rates declined from 19.4% to 2.6% for rTKA during the study period (P < .0001). Transfusions were more frequent in patients who were older, female, with more comorbidities, with lower hematocrit, receiving nonspinal anesthesia, and with longer operative time. Lower preoperative hematocrit, history of bleeding disorders, and preoperative transfusion were associated with greater odds for postoperative transfusion after multivariate analysis. CONCLUSION Transfusions after both primary and revision total joint arthroplasty have continued to decrease. Studies of arthroplasty complications should account for decreasing transfusions when assessing overall complication rates. Future studies should consider interventions to further reduce transfusions in revision arthroplasty.
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Affiliation(s)
- David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | | | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Timothy S Brown
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - John J Callaghan
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Nicholas A Bedard
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
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Feng T, Zhao J, Wang J, Sun X, Jia T, Li F. Anesthetic Effect of the Fascia Iliaca Compartment Block with Different Approaches on Total Hip Arthroplasty and Its Effect on Postoperative Cognitive Dysfunction and Inflammation. Front Surg 2022; 9:898243. [PMID: 35599808 PMCID: PMC9114884 DOI: 10.3389/fsurg.2022.898243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe objective of this article is to make a comparison of the anesthetic effects of the inside and outside fascia iliaca compartment block (FICB) in total hip arthroplasty (THA) and to study the effect of the different approaches of the FICB on postoperative cognitive dysfunction (POCD) and serum inflammatory cytokines in THA patients.MethodsA total of 60 patients who received THA treatment from January 2021 to December 2021 were divided into two groups, namely, Inside group (inside approach of the FICB) and Outside group (outside approach of the FICB), according to the different approaches of the FICB. Forty-eight hours after surgery, we compared the use of ropacaine dosage, visual analogue scale (VAS) score, the use of patient-controlled analgesia (PCA), mini-mental state examination (MMSE) score, the incidence of POCD, and the serum levels of IL-1, IL-6. Secondary indicators include surgical indicators and the quality of anesthesia cannula.ResultsThe ratio of re-fix the catheter, intubation time, and the use of ropacaine dosage at 48 h after surgery in the Outside group were significantly higher than that in the Inside group (p < 0.05), while the depth of cannulation in the Outside group was significantly lower than that in the Inside group (p < 0.05). VAS scores were comparable between the Inside and the Outside groups, except at 24 h after surgery. The use of PCA from 24 to 48 h after surgery in the Outside group was significantly higher than that in the Inside group (p < 0.05). The MMSE score and the incidence of POCD in the Outside group were higher than that in the Inside group. At the same time, the serum IL-1β levels at 1 and 6 h after surgery and the serum IL-6 levels at 1, 6, 24, and 48 h after surgery in the Outside group were significantly higher than that in the Inside group (p < 0.05).ConclusionCompared with the outside approach of the FICB, the inside approach of the FICB has better anesthetic effect, better postoperative analgesia, fewer postoperative analgesics, lower incidence of POCD, and lower serum cytokines during the treatment of THA patients.
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